Prevention of fetal alcohol spectrum disorders

Psychosocial and medication interventions to stop or reduce alcohol consumption during pregnancy

BACKGROUND

Despite the known harms, alcohol consumption is common in pregnancy. Rates vary between countries, and are estimated to be 10% globally, with up to 25% in Europe.

OBJECTIVES

To assess the efficacy of psychosocial interventions and medications to reduce or stop alcohol consumption during pregnancy.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO, from inception to 8 January 2024. We also searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). All searches included non-English language literature. We handsearched references of topic-related systematic reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials that compared medications or psychosocial interventions, or both, to placebo, no intervention, usual care, or other medications or psychosocial interventions used to reduce or stop alcohol use during pregnancy. Our primary outcomes of interest were abstinence from alcohol, reduction in alcohol consumption, retention in treatment, and women with any adverse event.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included eight studies (1369 participants) in which pregnant women received an intervention to stop or reduce alcohol use during pregnancy. In one study, almost half of participants had a current diagnosis of alcohol use disorder (AUD); in another study, 40% of participants had a lifetime diagnosis of AUD. Six studies took place in the USA, one in Spain, and one in the Netherlands. All included studies evaluated the efficacy of psychosocial interventions; we did not find any study that evaluated the efficacy of medications for the treatment of AUD during pregnancy. Psychosocial interventions were mainly brief interventions ranging from a single session of 10 to 60 minutes to five sessions of 10 minutes each. Pregnant women received the psychosocial intervention approximately at the end of the first trimester of pregnancy, and the outcome of alcohol use was reassessed 8 to 24 weeks after the psychosocial intervention. Women in the control group received treatment as usual (TAU) or similar treatments such as comprehensive assessment of alcohol use and advice to stop drinking during pregnancy. Globally, we found that, compared to TAU, psychosocial interventions may increase the rate of continuously abstinent participants (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.14 to 1.57; I2 =0%; 3 studies; 378 women; low certainty evidence). Psychosocial interventions may have little to no effect on the number of drinks per day, but the evidence is very uncertain (mean difference -0.42, 95% CI -1.13 to 0.28; I2 = 86%; 2 studies; 157 women; very low certainty evidence). Psychosocial interventions probably have little to no effect on the number of women who completed treatment (RR 0.98, 95% CI 0.94 to 1.02; I2 = 0%; 7 studies; 1283 women; moderate certainty evidence). None of the included studies assessed adverse events of treatments. We downgraded the certainty of the evidence due to risk of bias and imprecision of the estimates.

AUTHORS' CONCLUSIONS

Brief psychosocial interventions may increase the rate of continuous abstinence among pregnant women who report alcohol use during pregnancy. Further studies should be conducted to investigate the efficacy and safety of psychosocial interventions and other treatments (e.g. medications) for women with AUD. These studies should provide detailed information on alcohol use before and during pregnancy using consistent measures such as the number of drinks per drinking day. When heterogeneous populations are recruited, more detailed information on alcohol use during pregnancy should be provided to allow future systematic reviews to be conducted. Other important information that would enhance the usefulness of these studies would be the presence of other comorbid conditions such as anxiety, mood disorders, and the use of other psychoactive substances.

Effect of a communication intervention on alcohol use during pregnancy in post conflict Northern Uganda: a quasi experimental study

BACKGROUND

Alcohol use during pregnancy is a preventable risk factor for Fetal Alcohol Spectrum disorders. Psycho-social and educational interventions have been reported to enable women reduce alcohol intake levels during pregnancy and help improve some health outcomes of unhealthy alcohol use. We set out to assess the effect of a communication intervention on alcohol use during pregnancy in post conflict northern Uganda.

METHODS

The study employed a quasi - experimental design to assess the effect of a community health worker led communication strategy on pregnant women's knowledge, attitudes and various patterns of alcohol use using Difference in Difference(DiD). 420 respondents were recruited at baseline as at endline.

RESULTS

The communication messages were significantly associated with reduced odds of binge drinking (P = 0.018; OR = 0.09; CI = 0.012-0.66). Also those who received the intervention were less likely to drink frequently (P = 0.80; OR = 0.75; 95%CI = 0.074-7.5) or be harmful alcohol users(P = 0.948). The intervention also positively influenced having fair (β =0.49;P = 0.217;RRR =1.63)or adequate knowledge(β = 0.89;P = 0.25;RRR = 2.44) and having positive(β = 0.37;RRR =1.44;P = 0.46) or fair attitude(β = 0.19;RRR = 1.21; P = 0.693) although not to a significant level.

CONCLUSIONS

The communication intervention affected some patterns of alcohol use among pregnant women and not others. Our results contribute to existing evidence that communication interventions are a promising approach in reduction of alcohol exposed pregnancies. Interventions aimed at promoting alcohol abstinence during pregnancy should be implemented alongside other strategies that address factors that influence pregnant women to drink to achieve maximum results.

Binge-like Prenatal Ethanol Exposure Causes Impaired Cellular Differentiation in the Embryonic Forebrain and Synaptic and Behavioral Defects in Adult Mice

An embryo’s in-utero exposure to ethanol due to a mother’s alcohol drinking results in a range of deficits in the child that are collectively termed fetal alcohol spectrum disorders (FASDs). Prenatal ethanol exposure is one of the leading causes of preventable intellectual disability. Its neurobehavioral underpinnings warrant systematic research. We investigated the immediate effects on embryos of acute prenatal ethanol exposure during gestational days (GDs) and the influence of such exposure on persistent neurobehavioral deficits in adult offspring. We administered pregnant C57BL/6J mice with ethanol (1.75 g/kg) (GDE) or saline (GDS) intraperitoneally (i.p.) at 0 h and again at 2 h intervals on GD 8 and GD 12. Subsequently, we assessed apoptosis, differentiation, and signaling events in embryo forebrains (E13.5; GD13.5). Long-lasting effects of GDE were evaluated via a behavioral test battery. We also determined the long-term potentiation and synaptic plasticity-related protein expression in adult hippocampal tissue. GDE caused apoptosis, inhibited differentiation, and reduced pERK and pCREB signaling and the expression of transcription factors Pax6 and Lhx2. GDE caused persistent spatial and social investigation memory deficits compared with saline controls, regardless of sex. Interestingly, GDE adult mice exhibited enhanced repetitive and anxiety-like behavior, irrespective of sex. GDE reduced synaptic plasticity-related protein expression and caused hippocampal synaptic plasticity (LTP and LTD) deficits in adult offspring. These findings demonstrate that binge-like ethanol exposure at the GD8 and GD12 developmental stages causes defects in pERK–pCREB signaling and reduces the expression of Pax6 and Lhx2, leading to impaired cellular differentiation during the embryonic stage. In the adult stage, binge-like ethanol exposure caused persistent synaptic and behavioral abnormalities in adult mice. Furthermore, the findings suggest that combining ethanol exposure at two sensitive stages (GD8 and GD12) causes deficits in synaptic plasticity-associated proteins (Arc, Egr1, Fgf1, GluR1, and GluN1), leading to persistent FASD-like neurobehavioral deficits in mice.

Fetal alcohol syndrome knowledge and risk behaviors among university students and community residents in Limpopo, South Africa

The Republic of South Africa has the highest documented fetal alcohol syndrome prevalence globally. In the Limpopo province, little is known about students’ or community members’ knowledge of fetal alcohol syndrome or fetal alcohol spectrum disorder rates and risk behaviors. The aim of this study was to characterize and compare knowledge about fetal alcohol syndrome and other fetal alcohol spectrum disorders and the related behaviors such as drinking among University of Venda students and local community residents in villages to inform educational efforts to prevent fetal alcohol syndrome. Participants ([Formula: see text]) were from the University of Venda and two villages, Maungani and Ha-Mangilasi, and completed an epidemiological survey about their characteristics, behaviors, and fetal alcohol spectrum disorder risks. We analyzed differences between the university students and community residents in fetal alcohol syndrome knowledge and the related risk behaviors. University students have heard of fetal alcohol syndrome (Fisher’s exact test p < .001), have seen warning labels about drinking during pregnancy (Fisher’s exact test p = .003), and were aware that a baby is born with birth defects if diagnosed with fetal alcohol syndrome (Fisher’s exact test p = .03) with more knowledge of fetal alcohol syndrome compared to community residents. Most respondents thought it was unacceptable to drink during pregnancy. Despite this, a substantial number of participants thought it was acceptable to have one drink after pregnancy recognition. There was little knowledge of best practices about alcohol consumption to prepare for pregnancy, or once recognized. We recommend an education campaign to raise awareness of fetal alcohol spectrum disorders across Limpopo, especially in smaller villages, and further research to determine demographic and experiential risk factors to aid in prevention efforts.

Alcohol Use Trajectories Before and After Pregnancy Among Adolescent and Young Adult Mothers

BACKGROUND

Moderate to heavy alcohol use during pregnancy (≥3 drinks/occasion) is linked to a range of adverse offspring outcomes. Prior studies suggest that adolescent and young adult mothers may be particularly vulnerable to these risky drinking behaviors during and after pregnancy. This study used latent class growth analysis (LCGA) to examine changes in risky drinking from prepregnancy to postpregnancy and identified prepregnancy predictors representing cognitive and social factors to inform prevention.

METHODS

Participants included 432 adolescent and young adult mothers (aged 13 to 24; 78% Black) assessed annually since childhood in the Pittsburgh Girls Study. Participants prospectively reported frequency of risky drinking (≥3 drinks/occasion) in the year of pregnancy and 2 years before and after pregnancy, as well as social-cognitive risk factors for drinking (alcohol expectancies, drinking motives, caregiver, and peer alcohol use).

RESULTS

Approximately 11% of young mothers in this community-based sample engaged in risky drinking at least once a month during the year of pregnancy, with greater frequency observed for young adult (vs. adolescent) mothers. LCGA revealed 4 risky drinking trajectories across the perinatal period, including 3 relatively stable trajectories (low, moderate, and high frequency) and 1 distinct trajectory ("postpartum initiators") characterized by increased risky drinking post-childbirth. Peer alcohol use during and after pregnancy distinguished higher risk from lower risk trajectories, controlling for age, race, and age of drinking onset. Exposure to caregiver alcohol use and prepregnancy coping motives for drinking also elevated risk, but only for mothers who became pregnant in early adulthood (vs. adolescence).

CONCLUSIONS

Adolescent and young adult mothers show heterogeneous risky drinking trajectories from prepregnancy to postpregnancy. Pregnant women in the transitional age of early adulthood who report exposure to caregiver alcohol use, more friends who drink, and coping motives for drinking may have elevated risk for moderate-heavy drinking during the perinatal period and may benefit from targeted intervention.

Postnatal Ethanol Exposure Activates HDAC-Mediated Histone Deacetylation, Impairs Synaptic Plasticity Gene Expression and Behavior in Mice

BACKGROUND

Alcohol consumption during pregnancy is widespread and contributes to pediatric neurological defects, including hippocampal and neocortex dysfunction, causing cognitive deficits termed fetal alcohol spectrum disorders. However, the critical mechanisms underlying these brain abnormalities remain poorly described.

METHODS

Using a postnatal ethanol exposure (PEE) animal model and pharmacological, epigenetic, synaptic plasticity-related and behavioral approaches, we discovered a novel persistent epigenetic mechanism of neurodegeneration in neonatal hippocampus and neocortex brain regions and of cognitive decline in adult animals.

RESULTS

PEE, which activates caspase-3 (CC3, a neurodegeneration marker), enhanced histone deacetylase (HDAC1-HDAC3) levels and reduced histone 3 (H3) and 4 (H4) acetylation (ac) in mature neurons. PEE repressed the expression of several synaptic plasticity genes, such as brain-derived neurotrophic factor, C-Fos, early growth response 1 (Egr1), and activity-regulated cytoskeleton-associated protein (Arc). Detailed studies on Egr1 and Arc expression revealed HDAC enrichment at their promoter regions. HDAC inhibition with trichostatin A (TSA) before PEE rescued H3ac/H4ac levels and prevented CC3 formation. Antagonism/null mutation of cannabinoid receptor type-1 (CB1R) before PEE to inhibit CC3 production prevented Egr1 and Arc loss via epigenetic events. TSA administration before PEE prevented postnatal ethanol-induced loss of Egr1 and Arc expression and neurobehavioral defects in adult mice via epigenetic remodeling. In adult mice, 3-day TSA administration attenuated PEE-induced behavioral defects.

CONCLUSIONS

These findings demonstrate that CB1R/HDAC-mediated epigenetic remodeling disrupts gene expression and is a critical step in fetal alcohol spectrum disorder-associated cognitive decline but is reversed by restoration of histone acetylation in the brain.

Neurodevelopmental Outcomes Associated with Prefrontal Cortical Deoxygenation in Children with Fetal Alcohol Spectrum Disorders

Relationships between neurodevelopmental functioning and hemodynamic changes in the prefrontal cortex (PFC) were contrasted between children with prenatal alcohol exposure (PAE) and children who differed relative to their history of PAE and the presence of other neurodevelopmental impairment. For all groups, deoxygenated hemoglobin (HBR) levels in the medial PFC area were negatively related to externalizing problems and levels in the medial and right lateral PFC were positively related to errors on a cognitive inhibition task. Hemodynamic changes in the medial and right lateral PFC of children with PAE demonstrated stronger relationships to aspects of executive functioning relative to contrast groups.

Alcohol use, pregnancy and associated risk factors: a pilot cross-sectional study of pregnant women attending prenatal care in an urban city

BACKGROUND

Alcohol consumption during pregnancy is associated with adverse pregnancy outcomes such as preventable alcohol-related developmental disability fetal alcohol syndrome. In Zambia, alcohol use and associated risk factors have not been investigated, and screening in prenatal care is nonexistent. This study determined individual correlates and the prevalence of alcohol use in pregnant women attending prenatal care at two health clinics in Lusaka, Zambia.

METHODS

A study adopted a cross-sectional design and recruited 188 pregnant women after seeking their informed consent from July 19 to 31, 2017. Participants aged 18 or over completed the T-ACE (Tolerance, Annoyance, Cut Down and Eye Opener) screening tool and validated alcohol-screening questionnaires on self-reported alcohol use periconceptional and during conception period while at their regular prenatal visit. The T-ACE screening tool assessed the risk of alcohol dependence in four short questions. The questionnaires included demographic questions. Bivariate analyses were performed using the χ2 test for dichotomous variables and the t-test for continuous variables. Mixed-effects linear models were used to evaluate the effect of outcome variables with patient-level variables.

RESULTS

About 40 (21.2%) pregnant women were identified by the T-ACE as at-risk for problem drinking during pregnancy. Except for regular prenatal care and distance, there was no difference in the demographic factors between pregnant women who scored < 2 on the T-ACE and those that scored > 2 points (all p's > 0.05). A small proportional of women at both clinics reported binge drinking during the periconceptional period (12.7% vs. 3.2%, p = 0.003) and beyond periconception period. Excluding employed women, no significant relationships were observed between alcohol use and demographic factors.

CONCLUSION

Alcohol consumption is prevalent in the periconceptional period and during pregnancy in pregnant women attending prenatal care in Zambia. Findings underscore the need for targeted alcohol use screening and intervention for pregnant women.

Prenatal Alcohol Screening During Pregnancy by Midwives and Nurses

BACKGROUND

Alcohol use during pregnancy can have a variety of harmful consequences on the fetus. Lifelong effects include growth restriction, characteristic facial anomalies, and neurobehavioral dysfunction. This range of effects is known as fetal alcohol spectrum disorders (FASD). There is no amount, pattern, or timing of alcohol use during pregnancy proven safe for a developing embryo or fetus. Therefore, it is important to screen patients for alcohol use, inform them about alcohol's potential effects during pregnancy, encourage abstinence, and refer for intervention if necessary. However, how and how often nurses and midwives inquire about alcohol drinking during pregnancy or use recommended screening tools and barriers they perceive to alcohol screening has not been well established.

METHODS

This survey was sent to about 6,000 American midwives, nurse practitioners, and nurses who provide prenatal care about their knowledge of the effects of prenatal alcohol exposure, the prevalence of alcohol use during pregnancy, and practices for screening patients' alcohol use. Participants were recruited by e-mail from the entire membership roster of the American College of Nurse-Midwives.

RESULTS

There were 578 valid surveys returned (about 9.6%). Analyses showed that 37.7% of the respondents believe drinking alcohol is safe during at least one trimester of pregnancy. Only 35.2% of respondents reported screening to assess patient alcohol use. Only 23.3% reported using a specific screening tool, and few of those were validated screens recommended for use in pregnant women. Respondents who believe alcohol is safe at some point in pregnancy were significantly less likely to screen their patients.

CONCLUSIONS

Respondents who reported that pregnancy alcohol use is unsafe felt more prepared to educate and intervene with patients regarding alcohol use during pregnancy and FASD than respondents who reported drinking in pregnancy was safe. Perceived alcohol safety and perceived barriers to screening appeared to influence screening practices. Improving prenatal care provider knowledge about the effects of prenatal alcohol exposure and the availability of valid alcohol screening tools will improve detection of drinking during pregnancy, provide more opportunities for meaningful intervention, and ultimately reduce the incidence of FASD.

Community Perceptions of Alcohol Exposed Pregnancy Prevention Program for American Indian and Alaska Native Teens

A community needs assessment during a tribally-led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) intervention highlighted the need to reduce the risk for alcohol exposed pregnancy (AEP) among American Indian and Alaska Native (AIAN) adolescent girls. The CHOICES for American Indian Teens (CHAT) Program aims to reduce the risk of AEP among AIAN teens in one Northern Plains tribal community. The CHAT team adopted an iterative process to modify the tribally-led CHOICES curriculum for AIAN teens. This paper describes the iterative process as well as the community perception towards AEP prevention among AIAN teens. The CHAT team conducted several levels of formative and qualitative research, including one-on-one interviews (n = 15) with community members, AIAN elders and school counsellors; and three focus groups with AIAN adolescent girls (n = 15). A qualitative data analysis identified several recommendations that centered on making the information regarding alcohol and birth control appealing to teens; ensuring the confidentiality of the participants; making the program culturally relevant; and including boys in the program. This study outlines various components prioritized by community members in creating a culturally-relevant and age-appropriate AEP prevention program and provides community perceptions of AEP prevention for the teens in this community.

The past, present, and future of fetal alcohol spectrum disorder work in Newfoundland and Labrador: A landscape paper for change

OBJECTIVES

In this paper, we provide an overview of best practices in FASD prevention, diagnostic, and interventions and supports. In Canada, people diagnosed with Fetal Alcohol Spectrum Disorder (FASD) represent a fraction people living with FASD. While social stigma may deter people from seeking an FASD diagnosis, other deterrents include the lack of screening and diagnostic referrals, cost of travelling to a clinic, and lack of clarity of how a diagnosis may improve supports and services. Preventing FASD and improving lifelong outcomes for people living with FASD requires a coordinated approach between prevention, diagnostic, intervention, and support efforts.

METHODS

Using the example of Newfoundland and Labrador, a province where 60% of the population lives in rural communities and benefits from being involved in national initiatives and partnerships, we discuss efforts underway in other Canadian provinces to address FASD.

RESULTS

We make three recommendations that begin to address FASD-specific needs in both rural and urban regions: a) a provincial FASD consultant position, b) an explicit partnership between provincial government and fasdNL, and c) increased access to FASD diagnostic teams.

CONCLUSION

While the recommendations are both modest and essential first steps, we also suggest that collaborations and resource-sharing in FASD prevention and supports are more about doing things differently, rather than doing more.

A practice change intervention to improve antenatal care addressing alcohol consumption by women during pregnancy: research protocol for a randomised stepped-wedge cluster trial

Background

Despite clinical guideline recommendations, implementation of antenatal care addressing alcohol consumption by pregnant women is limited. Implementation strategies addressing barriers to such care may be effective in increasing care provision. The aim of this study is to examine the effectiveness, cost and cost-effectiveness of a multi-strategy practice change intervention in increasing antenatal care addressing the consumption of alcohol by pregnant women.

Methods

The study will be a randomised, stepped-wedge controlled trial conducted in three sectors in a health district in New South Wales, Australia. Stepped implementation of a practice change intervention will be delivered to sectors in a random order to support the introduction of a model of care for addressing alcohol consumption by pregnant women. A staged process was undertaken to develop the implementation strategies, which comprise of: leadership support, local clinical practice guidelines, electronic prompts and reminders, opinion leaders, academic detailing (audit and feedback), educational meetings and educational materials, and performance monitoring. Repeated cross-sectional outcome data will be gathered weekly across all sectors for the study duration. The primary outcome measures are the proportion of antenatal appointments at ‘booking in’, 27–28 weeks gestation and 35–36 weeks gestation for which women report (1) being assessed for alcohol consumption, (2) being provided with brief advice related to alcohol consumption during pregnancy, (3) receiving relevant care for addressing alcohol consumption during pregnancy, and (4) being assessed for alcohol consumption and receiving relevant care. Data on resources expended during intervention development and implementation will be collected. The proportion of women who report consuming alcohol since knowing they were pregnant will be measured as a secondary outcome.

Discussion

This will be the first randomised controlled trial to evaluate the effectiveness, cost and cost-effectiveness of implementation strategies in improving antenatal care that addresses alcohol consumption by pregnant women. If positive changes in clinical practice are found, this evidence will support health service adoption of implementation strategies to support improved antenatal care for this recognised risk to the health and wellbeing of the mother and child.

Trial registrations

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Convergence of online daily diaries and timeline followback among women at risk for alcohol exposed pregnancy

Researchers and clinicians interested in assessing drinking and unprotected sex in evaluating risk for alcohol-exposed pregnancy (AEP) have limited options. The current investigation examined the degree to which data collected from online prospectively collected daily diaries (Diaries) converged with data from interviewer-administered retrospective timeline follow back (TLFB), the standard in AEP intervention studies. 71 women (M_age=27.7, SD=6.2) at risk for AEP were recruited via online advertising and were randomly assigned to an online patient education condition or a tailored, online internet intervention to reduce AEP risk. All participants were administered both Diaries and TLFB at baseline and 6months after intervention. Key outcomes were variables of drinking rates and unprotected sex that combined to indicate risk for AEP. Zero-order and intra-class correlations (ICC) between Diaries and TLFB were strong for each outcome. Examination of ICC confidence intervals indicated that condition assignment did not have a significant impact on the degree of convergence between Diaries and TLFB. With the exception of proportion of days drinking and proportion of days with unprotected sex at baseline, none of the paired t-tests reached significance. Examination of descriptive statistics revealed that 63% of participants reported problem alcohol use and unprotected sex in both the 10-day Diaries and 90-day TLFB at baseline, with 70% agreement at post 6-month follow up. Findings indicate overall strong agreement between TLFB and Diaries in detecting alcohol use and unprotected sex in women at risk for AEP, and each method has benefits and challenges that should be weighed carefully by researchers and treatment providers.

Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial of a Self-Administered Version of Project CHOICES with College Students and Nonstudents

BACKGROUND

Alcohol-exposed pregnancies (AEPs) are a preventable cause of birth defects and developmental disabilities for which many women are at risk. The initial 5-session Project CHOICES intervention was found to prevent AEPs. In the ensuing decade, there have been several additional CHOICES-like studies. This study, Project Healthy CHOICES, had 2 objectives: (i) to compare outcomes for students versus nonstudents; and (ii) to test a self-administered mail-based version of the Project CHOICES intervention.

METHODS

A randomized controlled trial (RCT) compared 2 interventions for women of childbearing age (18 to 44) who were at risk of an AEP: (i) motivational feedback based on Project CHOICES and (ii) information only. Advertisements recruited 354 women (145 college students; 209 nonstudents) at risk of an AEP. Intervention and study materials were available in English and Spanish. Of the 354 women, 44% were minorities (25% identified as Hispanics).

RESULTS

At the 6-month follow-up, the interventions did not differ and there was no Intervention by Student Study interaction. However, over the entire 6-month follow-up, significantly more students (68%) than nonstudents (46%) were not at risk of an AEP (2.1 odds ratio; confidence interval = 1.47 to 2.95). For all groups, risk reduction occurred primarily through effective contraception.

CONCLUSIONS

There was no significant difference between the 2 interventions. However, over the entire 6-month follow-up interval, college students were significantly more likely than nonstudents to not be at risk of an AEP and to use effective contraception. While the student groups had significantly higher reduced risk of AEP outcomes, there was also substantial risk reduction for women in the information only condition. These results suggest that the most effective AEP prevention efforts would be to inform women at risk that they could become pregnant. Because about half of all pregnancies are unplanned, identifying women at risk and preventing the risk of AEPs should be a public health priority.

Changes in drinking patterns during and after pregnancy among mothers of children with fetal alcohol syndrome: A study in three districts of South Africa

BACKGROUND

Mixed ancestry populations in South Africa have amongst the highest rates of fetal alcohol syndrome (FAS) worldwide. Defining the drinking patterns of women with a FAS child guides FAS preventive interventions.

METHODS

Data were drawn from FAS prevalence surveys conducted in three districts: Witzenberg (Cape Winelands), Frances Baard (inland mining town) and Saldanha Bay (coastal towns). 156 mothers and 50 proxy informants of school-entry children diagnosed with FAS and partial-FAS were interviewed, and compared with 55 controls recruited in Saldanha Bay.

RESULTS

Study participants were of low socio-economic status (SES), and a majority of children were either in foster care (12%) or had been cared for by relatives for long periods (44%). Of cases, 123/160 (77%) reported current drinking, similar between sites. During pregnancy, only 35% (49/139) of cases had stopped drinking, varying between sites (from 21% to 54% in chronological order of surveys; p<0.001), while 6% (7/109) increased drinking. Though many women who stopped in pregnancy resumed postpartum, cessation in pregnancy was strongly associated with discontinuation in the long run (OR=3.3; 95%CI=1.2-8.9; p=0.005). At interview, 36% of cases (54/151) and 18% of controls (9/51) were at risk of an alcohol-exposed pregnancy (p=0.02). Median maternal mass of cases was 22kg lower than controls, with 20% being underweight and 14% microcephalic.

CONCLUSIONS

Increasing rates of drinking cessation during pregnancy over time suggest rising awareness of FAS. Cessation is associated with recidivism after pregnancy but also with reduced long-term drinking. Interventions should target alcohol abstinence in pregnancy, but extend into the puerperium.

Fetal alcohol spectrum disorders: Prevention, identification, and intervention

Fetal alcohol spectrum disorders (FASD) remain a common cause of intellectual disability in infants and children, with an estimated incidence of 9.1 out of every 1,000 U.S. live births. This article discusses methods for identifying and assisting women who consume alcohol prenatally and referring infants and children with FASD for intervention.

"Did you ever drink more?" A detailed description of pregnant women's drinking patterns

BACKGROUND

This paper presents drinking patterns in a prospective study of a population-based cohort of 1570 pregnant women using a combination of dose and timing to give best estimates of prenatal alcohol exposure (PAE). Novel assessments include women's special occasion drinking and alcohol use prior to pregnancy recognition.

METHODS

Information on up to nine types of alcoholic drink, with separate frequencies and volumes, including drinking on special occasions outside a 'usual' pattern, was collected for the periconceptional period and at four pregnancy time points. Weekly total and maximum alcohol consumption on any one occasion was calculated and categorised. Drinking patterns are described in the context of predictive maternal characteristics.

RESULTS

41.3 % of women did not drink during pregnancy, 27 % drank in first trimester only; most of whom stopped once they realised they were pregnant (87 %). When compared to women who abstained from alcohol when pregnant, those who drank in the first trimester only were more likely to have an unplanned pregnancy and not feel the effects of alcohol quickly. Almost a third of women continued to drink alcohol at some level throughout pregnancy (27 %), around half of whom never drank more than at low or moderate levels. When compared with abstainers and to women who only drank in trimester one, those who drank throughout pregnancy tended to be in their early to mid-thirties, smoke, have a higher income and educational attainment. Overall, almost one in five women (18.5 %) binge drank prior to pregnancy recognition, a third of whom were identified with a question about 'special occasion' drinking. Women whose age at first intoxication was less than 18 years (the legal drinking age in Australia), were significantly more likely to drink in pregnancy and at binge levels prior to pregnancy recognition.

CONCLUSIONS

We have identified characteristics of pregnant women who either abstain, drink until pregnancy awareness or drink throughout pregnancy. These may assist in targeting strategies to enhance adherence to an abstinence policy and ultimately allow for appropriate follow-up and interpretation of adverse child outcomes. Our methodology also produced important information to reduce misclassification of occasional binge drinking episodes and ensure clearly defined comparison groups.

Inflammatory responses to alcohol in the CNS: nuclear receptors as potential therapeutics for alcohol-induced neuropathologies

Fetal alcohol spectrum disorder (FASD), which results from ethanol exposure during pregnancy, and alcohol use disorder (AUD), which includes both binge and chronic alcohol abuse, are strikingly common and costly at personal and societal levels. These disorders are associated with significant pathology, including that observed in the CNS. It is now appreciated in both humans and animal models that ethanol can induce inflammation in the CNS. Neuroinflammation is hypothesized to contribute to the neuropathologic and behavioral consequences in FASD and AUD. In this review, we: 1) summarize the evidence of alcohol-induced CNS inflammation, 2) outline cellular and molecular mechanisms that may underlie alcohol induction of CNS inflammation, and 3) discuss the potential of nuclear receptor agonists for prevention or treatment of neuropathologies associated with FASD and AUD.

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE): Proposed DSM-5 Diagnosis

Over the past 40 years, a significant body of animal and human research has documented the teratogenic effects of prenatal alcohol exposure (PAE). Neurobehavioral Disorder associated with PAE is proposed as a new clarifying term, intended to encompass the neurodevelopmental and mental health symptoms associated with PAE. Defining this disorder is a necessary step to adequately characterize these symptoms and allow clinical assessment not possible using existing physically-based diagnostic schemes. Without appropriate diagnostic guidelines, affected individuals are frequently misdiagnosed and treated inappropriately (often to their considerable detriment) by mental health, educational, and criminal justice systems. Three core areas of deficits identified from the available research, including neurocognitive, self-regulation, and adaptive functioning impairments, are discussed and information regarding associated features and disorders, prevalence, course, familial patterns, differential diagnosis, and treatment of the proposed disorder are also provided.

Prevalence and influence factors of vitamin A deficiency of Chinese pregnant women

Background

Vitamin A plays an important role in the periods of rapid cellular growth and differentiation, especially during pregnancy, which is supplied by the mother to the fetus. The aim of this study is to assess the prevalence and potential influence factors of prenatal VAD of Chinese pregnant women.

Methods

China National Nutrition and Health Survey 2010–2013(CHNNS2010–2013) is a nationally representative cross-sectional study. It involved the random selection of 150 districts (urban) or counties (rural). Each site randomly selected 30 pregnant women. Because volume of blood and incomplete data was taken into consideration,the final sample was formed by 1209 participants. Serum retinol concentrations were measured by high performance liquid chromatography. Characteristics of the pregnant women were collected by a questionnaire. Comparing retinol level across categories of independent variables was tested by the Mann-Whitney U test. Logistic and linear regression analyses were used to identify influence factors of Chinese pregnant women.

Results

The mean serum retinol level of the pregnant women was 1.63 μmol/L (95 % CI 1.60–1.67) and 64[5.3 % (95 % CI 4.03–6.56)] had VAD. The odds of VAD were significantly higher among the pregnant women in the poor rural areas and without college or university education and low- income. Pregnant women in the second and third trimester had 2.40 (95 % CI 1.05–5.46) and 2.82 (95 % CI 1.34–5.93) times increased odds of VAD compared with those in the first trimester respectively. Pregnant women of drinker had 3.10(1.65–5.81) times increased odds of VAD compared with those no drinker. Pregnant smokers had 5.68 (95 % CI 2.23–14.49) times higher odds of VAD compared with pregnant with non-smoker without passive smoking.

Conclusions

VAD is of mild public-health issue in Chinese pregnant women. Such as : in the poor rural areas and without received college or university education and low- income and advanced gestational age and unhealthy lifestyles of pregnant women such as smoking and drinking. These were pertinent influence factors of VAD.

Prevalence and characteristics of women at risk for an alcohol-exposed pregnancy (AEP) in the United States: estimates from the National Survey of Family Growth

Non-pregnant women can avoid alcohol-exposed pregnancies (AEPs) by modifying drinking and/or contraceptive practices. The purpose of this study was to estimate the number and characteristics of women in the United States who are at risk of AEPs. We analyzed data from in-person interviews obtained from a national probability sample (i.e., the National Survey of Family Growth) of reproductive-aged women conducted from January 2002 to March 2003. To be at risk of AEP, a woman had to have met the following criteria in the last month: (1) was drinking; (2) had vaginal intercourse with a man; and (3) did not use contraception. During a 1-month period, nearly 2 million U.S. women were at risk of an AEP (95 % confidence interval 1,760,079-2,288,104), including more than 600,000 who were binge drinking. Thus, 3.4 %, or 1 in 30, of all non-pregnant women were at risk of an AEP. Most demographic and behavioral characteristics were not clearly associated with AEP risk. However, pregnancy intention was strongly associated with AEP risk (prevalence ratio = 12.0, P < 0.001) because women often continued to drink even after they stopped using contraception. Nearly 2 million U.S. women are at AEP risk and therefore at risk of having children born with fetal alcohol spectrum disorders. For pregnant women and women intending a pregnancy, there is an urgent need for wider implementation of prevention programs and policy approaches that can reduce the risk for this serious public health problem.

Fetal Alcohol Spectrum Disorders

Prenatal exposure to alcohol can damage the developing fetus and is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities. In 1973, fetal alcohol syndrome was first described as a specific cluster of birth defects resulting from alcohol exposure in utero. Subsequently, research unequivocally revealed that prenatal alcohol exposure causes a broad range of adverse developmental effects. Fetal alcohol spectrum disorder (FASD) is the general term that encompasses the range of adverse effects associated with prenatal alcohol exposure. The diagnostic criteria for fetal alcohol syndrome are specific, and comprehensive efforts are ongoing to establish definitive criteria for diagnosing the other FASDs. A large and growing body of research has led to evidence-based FASD education of professionals and the public, broader prevention initiatives, and recommended treatment approaches based on the following premises:▪ Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use.▪ Neurocognitive and behavioral problems resulting from prenatal alcohol exposure are lifelong.▪ Early recognition, diagnosis, and therapy for any condition along the FASD continuum can result in improved outcomes.▪ During pregnancy:◦no amount of alcohol intake should be considered safe;◦there is no safe trimester to drink alcohol;◦all forms of alcohol, such as beer, wine, and liquor, pose similar risk; and◦binge drinking poses dose-related risk to the developing fetus.

Fetal Alcohol Spectrum Disorder: Potential Role of Endocannabinoids Signaling

One of the unique features of prenatal alcohol exposure in humans is impaired cognitive and behavioral function resulting from damage to the central nervous system (CNS), which leads to a spectrum of impairments referred to as fetal alcohol spectrum disorder (FASD). Human FASD phenotypes can be reproduced in the rodent CNS following prenatal ethanol exposure. Several mechanisms are expected to contribute to the detrimental effects of prenatal alcohol exposure on the developing fetus, particularly in the developing CNS. These mechanisms may act simultaneously or consecutively and differ among a variety of cell types at specific developmental stages in particular brain regions. Studies have identified numerous potential mechanisms through which alcohol can act on the fetus. Among these mechanisms are increased oxidative stress, mitochondrial damage, interference with the activity of growth factors, glia cells, cell adhesion molecules, gene expression during CNS development and impaired function of signaling molecules involved in neuronal communication and circuit formation. These alcohol-induced deficits result in long-lasting abnormalities in neuronal plasticity and learning and memory and can explain many of the neurobehavioral abnormalities found in FASD. In this review, the author discusses the mechanisms that are associated with FASD and provides a current status on the endocannabinoid system in the development of FASD.

Patterns of domestic violence and alcohol consumption among women and the effectiveness of a brief intervention in a household setting: a protocol study

BACKGROUND

Domestic violence and harmful alcohol consumption are considered major public health problems worldwide. These phenomena often co-occur, and they share several risk factors. Nevertheless, few in-depth studies have supported integrated interventions for both phenomena, in particular among Latin American women. This project will study the consumption of alcoholic beverages among women and its relationship with patterns of domestic violence; furthermore, it will assess the effect of a brief intervention (BI) aimed at modifying these behaviors using a community household sample.

METHODS/DESIGN

This project is divided into two studies. Study 1 will employ a cross-sectional observational design and will be conducted using a household sample of adult women (approximate sample size = 1600) to assess harmful alcohol consumption and domestic violence patterns. Study 2, will be a randomized clinical trial based on specific cases from Study 1, assessing the effect of a brief intervention on women who exhibit harmful levels of alcohol consumption (AUDIT ≥ 8). Approximately 73 women will be assigned to one of two groups, either a treated group (TG) or a control group (CG). A sociodemographic questionnaire, a questionnaire concerning general health and substance use, and four other standardized instruments (i.e., the Alcohol Use Disorder Identification Test [AUDIT; used to investigate problems related to alcohol consumption], the Center for Epidemiologic Studies Depression Scale [CES-D; used to measure depressive symptoms], and the Revised Conflict Tactics Scales and Parent-child Conflict Tactics Scales [CTS2 and CTSPC; used to obtain information on violence among couples and between parents and children, respectively]) will be used to collect data.

DISCUSSION

The study protocol will employ a household survey of a representative sample from a neighborhood in a middle income country, where well-conducted household surveys remain rare. The present work represents a step toward a better understanding of violence in women's lives and its interaction with alcohol consumption and expands the discussion on the potential strategies for public health actions seeking to prevent both domestic violence and harmful alcohol consumption.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry: RBR-7rjt4t. Registered 17 October 2013.

Pioglitazone blocks ethanol induction of microglial activation and immune responses in the hippocampus, cerebellum, and cerebral cortex in a mouse model of fetal alcohol spectrum disorders

BACKGROUND

Fetal alcohol spectrum disorders (FASD) result from fetal exposure to alcohol and are the leading cause of mental retardation in the United States. There is currently no effective treatment that targets the causes of these disorders. Thus, novel therapies are critically needed to limit the neurodevelopmental and neurodegenerative pathologies associated with FASD.

METHODS

A neonatal mouse FASD model was used to examine the role of the neuroimmune system in ethanol (EtOH)-induced neuropathology. Neonatal C57BL/6 mice were treated with EtOH, with or without pioglitazone, on postnatal days 4 through 9, and tissue was harvested 1 day post treatment. Pioglitazone is a peroxisome proliferator-activated receptor (PPAR)-γ agonist that exhibits anti-inflammatory activity and is neuroprotective. We compared the effects of EtOH with or without pioglitazone on cytokine and chemokine expression and microglial morphology in the hippocampus, cerebellum, and cerebral cortex.

RESULTS

In EtOH-treated animals compared with controls, cytokines interleukin-1β and tumor necrosis factor-α mRNA levels were increased significantly in the hippocampus, cerebellum, and cerebral cortex. Chemokine CCL2 mRNA was increased significantly in the hippocampus and cerebellum. Pioglitazone effectively blocked the EtOH-induced increase in the cytokines and chemokine in all tissues to the level expressed in handled-only and vehicle-treated control animals. EtOH also produced a change in microglial morphology in all brain regions that was indicative of microglial activation, and pioglitazone blocked this EtOH-induced morphological change.

CONCLUSIONS

These studies indicate that EtOH activates microglia to a pro-inflammatory stage and also increases the expression of neuroinflammatory cytokines and chemokines in diverse regions of the developing brain. Further, the anti-inflammatory and neuroprotective PPAR-γ agonist pioglitazone blocked these effects. It is proposed that microglial activation and inflammatory molecules expressed as a result of EtOH treatment during brain development contribute to the sequelae associated with FASD. Thus, pioglitazone and anti-inflammatory pharmaceuticals more broadly have potential as novel therapeutics for FASD.

Evaluation of an authority innovation-decision: brief alcohol intervention for pregnant women receiving women, infants, and children services at two Illinois health departments

Despite the availability of clinical tools and evidence-based screening recommendations, there has been little discussion regarding screening of prenatal alcohol exposure in community-based settings, including adoption and implementation. This study's aim is to evaluate and validate--through surveys and focus groups--obstacles and challenges that shape efficacious implementation of the BAI at two Illinois health departments. Results suggest that BAI implementation is facilitated by staff perceptions of its benefits, readiness to implement the intervention, and organizational support for it. Limitations of the management information system, ambiguous screening questions, and high case-loads present barriers to effective BAI implementation.

Gene expression signatures affected by alcohol-induced DNA methylomic deregulation in human embryonic stem cells

Stem cells, especially human embryonic stem cells (hESCs), are useful models to study molecular mechanisms of human disorders that originate during gestation. Alcohol (ethanol, EtOH) consumption during pregnancy causes a variety of prenatal and postnatal disorders collectively referred to as fetal alcohol spectrum disorders (FASDs). To better understand the molecular events leading to FASDs, we performed a genome-wide analysis of EtOH's effects on the maintenance and differentiation of hESCs in culture. Gene Co-expression Network Analysis showed significant alterations in gene profiles of EtOH-treated differentiated or undifferentiated hESCs, particularly those associated with molecular pathways for metabolic processes, oxidative stress, and neuronal properties of stem cells. A genome-wide DNA methylome analysis revealed widespread EtOH-induced alterations with significant hypermethylation of many regions of chromosomes. Undifferentiated hESCs were more vulnerable to EtOH's effect than their differentiated counterparts, with methylation on the promoter regions of chromosomes 2, 16 and 18 in undifferentiated hESCs most affected by EtOH exposure. Combined transcriptomic and DNA methylomic analysis produced a list of differentiation-related genes dysregulated by EtOH-induced DNA methylation changes, which likely play a role in EtOH-induced decreases in hESC pluripotency. DNA sequence motif analysis of genes epigenetically altered by EtOH identified major motifs representing potential binding sites for transcription factors. These findings should help in deciphering the precise mechanisms of alcohol-induced teratogenesis.

Dihydromyricetin prevents fetal alcohol exposure-induced behavioral and physiological deficits: the roles of GABAA receptors in adolescence

Fetal alcohol exposure (FAE) can lead to a variety of behavioral and physiological disturbances later in life. Understanding how alcohol (ethanol, EtOH) affects fetal brain development is essential to guide the development of better therapeutics for FAE. One of EtOH's many pharmacological targets is the γ-aminobutyric acid type A receptor (GABAAR), which plays a prominent role in early brain development. Acute EtOH potentiates inhibitory currents carried by certain GABAAR subtypes, whereas chronic EtOH leads to persistent alterations in GABAAR subunit composition, localization and function. We recently introduced a flavonoid compound, dihydromyricetin (DHM), which selectively antagonizes EtOH's intoxicating effects in vivo and in vitro at enhancing GABAAR function as a candidate for alcohol abuse pharmacotherapy. Here, we studied the effect of FAE on physiology, behavior and GABAAR function of early adolescent rats and tested the utility of DHM as a preventative treatment for FAE-induced disturbances. Gavage administration of EtOH (1.5, 2.5, or 5.0 g/kg) to rat dams on day 5, 8, 10, 12, and 15 of pregnancy dose-dependently reduced female/male offspring ratios (largely through decreased numbers of female offspring) and offspring body weights. FAE (2.5 g/kg) rats tested on postnatal days (P) 25-32 also exhibited increased anxiety and reduced pentylenetetrazol (PTZ)-induced seizure threshold. Patch-clamp recordings from dentate gyrus granule cells (DGCs) in hippocampal slices from FAE (2.5 g/kg) rats at P25-35 revealed reduced sensitivity of GABAergic miniature inhibitory postsynaptic currents (mIPSCs) and tonic current (Itonic) to potentiation by zolpidem (0.3 μM). Interestingly, potentiation of mIPSCs by gaboxadol increased, while potentiation of Itonic decreased in DGCs from FAE rats. Co-administration of EtOH (1.5 or 2.5 g/kg) with DHM (1.0 mg/kg) in pregnant dams prevented all of the behavioral, physiological, and pharmacological alterations observed in FAE offspring. DHM administration alone in pregnant rats had no adverse effect on litter size, progeny weight, anxiety level, PTZ seizure threshold, or DGC GABAAR function. Our results indicate that FAE induces long-lasting alterations in physiology, behavior, and hippocampal GABAAR function and that these deficits are prevented by DHM co-treatment of EtOH-exposed dams. The absence of adverse side effects and the ability of DHM to prevent FAE consequences suggest that DHM is an attractive candidate for development as a treatment for prevention of fetal alcohol spectrum disorders.

A novel integration effort to reduce the risk for alcohol-exposed pregnancy among women attending urban STD clinics

Alcohol-exposed pregnancy (AEP) is a significant public health problem in the United States. Sexually transmitted disease (STD) clinics serve female clients with a high prevalence of heavy alcohol consumption coupled with ineffective contraceptive use. Project CHOICES (Changing High-Risk AlcOhol Use and Increasing Contraception Effectiveness) is an evidence-based, brief intervention to lower risk of AEP by targeting alcohol and contraceptive behaviors through motivational interviewing and individualized feedback. We describe our experience integrating and implementing CHOICES in STD clinics. This endeavor aligns with CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's program collaboration and service integration strategic priority to strengthen collaborative work across disease areas and integrate services provided by related programs at the client level.

Performance measurement: a proposal to increase use of SBIRT and decrease alcohol consumption during pregnancy

Alcohol consumption during pregnancy has negative implications for maternal and child health. Appropriate early universal Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant women is necessary to identify women at risk and reduce the likelihood of continued drinking. Because SBIRT is not consistently used, the development and use of performance measures to assure implementation of SBIRT are key steps towards intervention and reduction of alcohol consumption during pregnancy. Practice guidelines provide ample support for specific instruments designed for SBIRT in prenatal care. An examination of existing performance measures related to alcohol consumption during pregnancy, however, reveals no comprehensive published performance measure designed to quantify the use of SBIRT for alcohol use in prenatal care. Process performance measures were developed that can determine the proportion of pregnant women who are screened during the course of prenatal care and the proportion of women requiring either brief intervention or referral to substance use disorder treatment who received those interventions. The measures require use of screening instruments validated for use with pregnant women. The two proposed measures would represent a significant step in efforts to assure appropriate intervention for women who drink during pregnancy, hold accountable providers who do not employ SBIRT, and provide a basis from which necessary systemic changes might occur. Pregnancy is a time when many women are motivated to stop drinking. That opportunity should be seized, with timely intervention offering assistance for pregnant women who have not stopped drinking of their own accord.

Fetal alcohol spectrum disorders and neuroimmune changes

The behavioral consequences of fetal alcohol spectrum disorders (FASD) are serious and persist throughout life. The causative mechanisms underlying FASD are poorly understood. However, much has been learned about FASD from human structural and functional studies as well as from animal models, which have provided a greater understanding of the mechanisms underlying FASD. Using animal models of FASD, it has been recently discovered that ethanol induces neuroimmune activation in the developing brain. The resulting microglial activation, production of proinflammatory molecules, and alteration in expression of developmental genes are postulated to alter neuron survival and function and lead to long-term neuropathological and cognitive defects. It has also been discovered that microglial loss occurs, reducing microglia's ability to protect neurons and contribute to neuronal development. This is important, because emerging evidence demonstrates that microglial depletion during brain development leads to long-term neuropathological and cognitive defects. Interestingly, the behavioral consequences of microglial depletion and neuroimmune activation in the fetal brain are particularly relevant to FASD. This chapter reviews the neuropathological and behavioral abnormalities of FASD and delineates correlates in animal models. This serves as a foundation to discuss the role of the neuroimmune system in normal brain development, the consequences of microglial depletion and neuroinflammation, the evidence of ethanol induction of neuroinflammatory processes in animal models of FASD, and the development of anti-inflammatory therapies as a new strategy for prevention or treatment of FASD. Together, this knowledge provides a framework for discussion and further investigation of the role of neuroimmune processes in FASD.

Reducing fetal alcohol exposure in the United States

Fetal alcohol exposure is the leading preventable cause of birth and developmental defects in the United States. Despite a growing body of knowledge about the spectrum of disorders resulting from fetal alcohol exposure, 1 in 9 pregnant women continues to drink alcohol during pregnancy, and a small percentage of pregnant women continues to binge drink. Health care providers do not consistently screen pregnant women for alcohol use, nor do health professionals necessarily know how to counsel pregnant women effectively about the risks of fetal alcohol exposure. In this article, we review the epidemiology of fetal alcohol exposure and discuss current strategies for screening and prevention of fetal alcohol exposure. We also explore the multiple barriers that exist toward reducing alcohol-exposed pregnancies from the patient, provider, and systems perspectives. Finally, we make recommendations for improved clinical and public health strategies to eliminate fetal alcohol exposure in the United States.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians.

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to describe rates of fetal alcohol exposure in the United States, describe the demographic characteristics of women at highest risk for fetal alcohol exposure, counsel patients appropriately regarding the risk of poor fetal outcomes in association with fetal alcohol exposure, and understand the barriers to effective counseling about fetal alcohol exposure.

Brief intervention and decrease of alcohol consumption among women: a systematic review

Problems related to alcohol consumption are priority public health issues worldwide and may compromise women's health. The early detection of risky alcohol consumption combined with a brief intervention (BI) has shown promising results in prevention for different populations. The aim of this study was to examine data from recent scientific publications on the use of BI toward reducing alcohol consumption among women through a systematic review. Electronic searches were conducted using Web of Science, PubMed(Medline) and PsycInfo databases. In all databases, the term "brief intervention" was associated with the words "alcohol" and "women", and studies published between the years 2006 and 2011 were selected. Out of the 133 publications found, the 36 scientific articles whose central theme was performing and/or evaluating the effectiveness of BI were included. The full texts were reviewed by content analysis technique. This review identified promising results of BI for women, especially pregnant women and female college students, in different forms of application (face-to-face, by computer or telephone) despite a substantial heterogeneity in the clinical trials analyzed. In primary care, which is a setting involving quite different characteristics, the results among women were rather unclear. In general, the results indicated a decrease in alcohol consumption among women following BI, both in the number of days of consumption and the number of doses, suggesting that the impact on the woman's reproductive health and the lower social acceptance of female consumption can be aspects favorable for the effectiveness of BI in this population.

Online training on fetal alcohol spectrum disorders for court-appointed special advocates volunteers

Fetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disabilities. Children within the child welfare system are five to 10 times more likely than other children to experience these symptoms. Court Appointed Special Advocates (CASA) volunteers are uniquely positioned to identify these children and refer them for assessment and services. This study used a one-group pretest-posttest design to assess the impact of a three-hour online FASDs training on CASA workers' knowledge of FASDs and their comfort and confidence in identifying children with FASDs for referral, advocating for them, and linking them to services. The training and assessment measures were completed by 338 CASA volunteers and staff from 55 CASA locations in Texas. Wilcoxon matched-pairs tests and paired t tests were used to assess change in each of the dependent measures. All comfort and confidence items showed significant improvement from pretest to posttest; there was also a significant improvement in knowledge. These results support the potential of this online training to enhance CASA volunteers' ability to help children with FASDs.

Preconceptional motivational interviewing interventions to reduce alcohol-exposed pregnancy risk

Alcohol exposed pregnancy (AEP) is a leading cause of preventable birth defects. While randomized controlled trials (RCTs) have shown that multi-session motivational interviewing-based interventions reduce AEP risk, a one-session intervention could facilitate broader implementation. The purposes of this study were to: (1) test a one-session motivational AEP prevention intervention for community women and (2) compare outcomes to previous RCTs. Participants at risk for AEP (N=217) were randomized to motivational interviewing+assessment feedback (EARLY), informational video, or informational brochure conditions. Outcomes were drinks per drinking day (DDD), ineffective contraception rate, and AEP risk at 3 and 6 months. All interventions were associated with decreased DDD, ineffective contraception rate, and AEP risk. Participants who received EARLY had larger absolute risk reductions in ineffective contraception and AEP risk, but not DDD. Effect sizes were compared to previous RCTs. The one-session EARLY intervention had less powerful effects than multi-session AEP prevention interventions among community women, but may provide a new option in a continuum of preventive care.

Identification of cell-specific patterns of reference gene stability in quantitative reverse-transcriptase polymerase chain reaction studies of embryonic, placental and neural stem models of prenatal ethanol exposure

Identification of the transcriptional networks disrupted by prenatal ethanol exposure remains a core requirement to better understanding the molecular mechanisms of alcohol-induced teratogenesis. In this regard, quantitative reverse-transcriptase polymerase chain reaction (qPCR) has emerged as an essential technique in our efforts to characterize alterations in gene expression brought on by exposure to alcohol. However, many publications continue to report the utilization of inappropriate methods of qPCR normalization, and for many in vitro models, no consistent set of empirically tested normalization controls have been identified. In the present study, we sought to identify a group of candidate reference genes for use within studies of alcohol exposed embryonic, placental, and neurosphere stem cells under both conditions maintaining stemness as well as throughout in vitro differentiation. To this end, we surveyed the recent literature and compiled a short list of fourteen candidate genes commonly used as normalization controls in qPCR studies of gene expression. This list included: Actb, B2m, Gapdh, Gusb, H2afz, Hk2, Hmbs, Hprt, Mrpl1, Pgk1, Ppia, Sdha, Tbp, and Ywhaz. From these studies, we find no single candidate gene was consistently refractory to the influence of alcohol nor completely stable throughout in vitro differentiation. Accordingly, we propose normalizing qPCR measurements to the geometric mean C(T) values obtained for three independent reference mRNAs as a reliable method to accurately interpret qPCR data and assess alterations in gene expression within alcohol treated cultures. Highlighting the importance of careful and empirical reference gene selection, the commonly used reference gene Actb was often amongst the least stable candidate genes tested. In fact, it would not serve as a valid normalization control in many cases. Data presented here will aid in the design of future experiments using stem cells to study the transcriptional processes driving differentiation, and model the developmental impact of teratogens.

Validation of the alcohol use module from a multidimensional prenatal psychosocial risk screening instrument

The purpose of the study was to validate the Prenatal Risk Overview (PRO) Alcohol use domain against a structured diagnostic interview. The PRO was developed to screen for 13 psychosocial risk factors associated with poor birth outcomes. After clinic staff administered the PRO to prenatal patients, they asked for consent to administration of selected modules of the structured clinical interview for DSM-IV (SCID) by a research assistant. To assess the criterion validity of the PRO, low and moderate/high risk classifications from the alcohol use domain were cross-tabulated with SCID Alcohol Use Disorder variables. The study sample included 744 women. Based on PRO responses, 48.7% reported alcohol use during the 12 months before they learned they were pregnant; 5.4% reported use post pregnancy awareness. The typical quantity consumed pre-pregnancy was four or more drinks per occasion. Based on the SCID, 7.4% met DSM-IV criteria for either Alcohol Abuse or Dependence. Sensitivity and specificity of the PRO for Alcohol Use Disorders were 83.6 and 80.3%, respectively. Negative predictive value was 98.4% and positive predictive value was 25.3%. The results indicate the PRO effectively identified pregnant women with Alcohol Use Disorders. However, prenatal screening must also detect consumption patterns that do not meet diagnostic thresholds but may endanger fetal development. The PRO also identified women who continued to drink after they knew they were pregnant, as well as those whose previous drinking habits put them at risk for resumption of hazardous use.

Maternal factors associated with heavy periconceptional alcohol intake and drinking following pregnancy recognition: a post-partum survey of New Zealand women

INTRODUCTION AND AIMS

Alcohol consumption during pregnancy places the foetus at risk of Foetal Alcohol Spectrum Disorders. Little is known about the current prevalence and patterns of alcohol consumption before and following pregnancy recognition in New Zealand.

DESIGN AND METHODS

A retrospective survey of 723 post-partum women resident in maternity wards located across New Zealand was conducted using a self-administered questionnaire. Maternal sociodemographic and obstetric characteristics and alcohol intake before and after pregnancy recognition were assessed.

RESULTS

Of the 968 women invited to participate, 78% agreed. Eighty-two percent of women reported consuming alcohol prior to pregnancy and 20% reported typically consuming >4 New Zealand standard drinks per occasion. Overall, 34% of women reported drinking at some time during pregnancy. Twelve percent of pregnancies were at high risk of heavy alcohol exposure in early gestation. In fully adjusted analysis, pregnancies most at risk were those of indigenous Māori women, Pacific women, smokers and drug users. Almost one-quarter (24%) of drinkers continued to drink following pregnancy recognition, and in fully adjusted analysis, continuing to drink was positively associated with frequency of alcohol consumption before pregnancy (P < 0.001 for linear trend).

DISCUSSION AND CONCLUSIONS

To reduce the burden of alcohol-related harm to the foetus, these findings suggest that New Zealand alcohol policy should be focused not only on promoting total abstinence when planning a pregnancy and when pregnant, but also on reducing 'binge drinking' culture and the frequent consumption of lower levels of alcohol.

CHOICES: an integrated behavioral intervention to prevent alcohol-exposed pregnancies among high-risk women in community settings

CHOICES is an integrated behavioral intervention for prevention of prenatal alcohol exposure in women at high risk for alcohol-exposed pregnancies. The intervention uses motivational interviewing and cognitive-behavioral strategies, and targets adoption of effective contraception and reduction of alcohol use. The CHOICES intervention includes four manual-guided counseling sessions delivered by behavioral health counselors and one contraceptive session with a family planning clinician. CHOICES's efficacy has been established through a series of randomized controlled trials in settings including primary care, university hospital-based obstetrical/gynecology practices, urban jails, substance abuse treatment settings, and a media-recruited sample in three large cities. This article describes the CHOICES line of research including the epidemiology, feasibility, and efficacy studies. It also details the CHOICES intervention and the components of each session. In addition, the authors describe current studies testing modifications of the CHOICES intervention, the dissemination efforts to date, and implications for social work practice.

Congenital malformations in Ecuadorian children: urgent need to create a National Registry of Birth Defects

AIM

This study sets out (a) to estimate the prevalence of admissions by birth defects, using the official database of hospitals of Ecuador; and (b) to set the basis for a new National Register of Birth Defects in Ecuador that works as a program for the clinical and epidemiological investigation of risk factors in the etiology of congenital anomalies in Ecuadorian hospitals, using a case-control methodological approach. This is the first report in their class.

METHODS

The data used in this study are derived from the National Register of Hospital Admission/Discharges of the Instituto Nacional de Estadísticas y Censos; data of the Ministry of Public Health were also used. Ecuador does not have an official Medical Birth Registry or a Congenital Malformations Registry.

RESULTS

A total of 51,375 discharges by congenital malformations were registered in a 7-year period. Of these, 16,679 admissions were of children aged less than 1 year of age, with a birth prevalence rate (BPR) of 72.33/10,000 births. 77% of the congenital defects registered comprise the 50 most common birth defects observed in this age group. Cleft lip was the most prevalent birth defect in children less than 1 year of age and the second most common defect in children 1 to 5 years of age. Unilateral cleft lip shows a BPR of 4.57/10,000 births; cardiac birth defects as a group have a BPR of 4.2; hydrocephalus a BPR of 3.77; and Down's syndrome a BPR of 3.70. Undescended testicle was the most prevalent birth defect in children between 1 to 5 years. 9384 children under 1 year of age were male (55.9%) and 7053 were female (42.1%). BPR in males was 40.45 and in females 30.40.

CONCLUSION

This report documents the prevalence estimates for birth defects reported in the hospital discharge data. These estimates are important to 1) plan for health-care and education needs of the Ecuadorian population, 2) identify increased occurrences of birth defects in specific geographic regions, 3) serve as a reference point for assessment of provincial surveillance systems, 4) evaluate national public health interventions, 5) compare Ecuador prevalence estimates with those of other countries, and 6) help determine the appropriate allocation of resources for basic and public health research. There is an urgent need to establish a National Registry of Birth Defects involving different sources of information such as prenatal medical records, birth records and medical records during the first year of life at an early stage, and surveys on cytogenetic prenatal diagnostic surveys and cytogenetics of therapeutic abortions.

Alcohol consumption among pregnant women in a Swedish sample and its effects on the newborn outcomes

BACKGROUND

Little is known about the effects of low levels of maternal alcohol intake on the neuropsychological development of the child. This study is part of an ongoing investigation on maternal drinking and presents data on demographic variables, maternal alcohol use, and birth outcomes from that study.

METHODS

The sample comprised 2,264 women from a Swedish antenatal clinic. Retrospective self-report data were collected on alcohol consumption before and during pregnancy, using the Alcohol Use Disorders Identification Test (AUDIT), and on nicotine use. Specific alcohol biomarkers for excessive drinking, carbohydrate-deficient transferrin (CDT) in serum and phosphatidylethanol (PEth) in whole blood, were determined during mid-pregnancy in a subsample of the women. Data on labor and early characteristics of the child were also assessed.

RESULTS

Before pregnancy, 89% of the women regularly consumed alcohol and 49% reported occasional or frequent binge drinking. Nicotine was used by 15% before and by 5% during pregnancy. During pregnancy, 12% continued using alcohol and 5% also admitted binge drinking. However, all alcohol biomarker values were below the reporting limits (CDT ≤ 1.7% disialotransferrin; total PEth < 0.1 μmol/L). Self-reported drinking during pregnancy was associated with a higher AUDIT score before pregnancy, nicotine use at the time of the first prenatal visit, older age, and previous legal abortions.

CONCLUSIONS

The AUDIT questionnaire and 2 specific alcohol biomarkers were used in routine maternity care to collect information about drinking during pregnancy and thereby to identify children at risk for alcohol-related complications. While the AUDIT results suggested that a significant number of women continued using alcohol during pregnancy, implying a risk for fetal disorders, the biomarkers showed negative test values thus indicating only modest drinking levels.

Universal prevention is associated with lower prevalence of fetal alcohol spectrum disorders in Northern Cape, South Africa: a multicentre before-after study

AIMS

Prevalence of fetal alcohol spectrum disorders (FASDs) is remarkably high in several provinces of South Africa; yet population-level knowledge of the harms of maternal drinking remains low. In two heavily affected areas, we assessed effectiveness of interventions to heighten awareness of these harms and to alter social norms about drinking in pregnancy.

METHODS

FASD prevalence, maternal knowledge and drinking behaviours were investigated in two Northern Cape Province towns, before and after interventions which included highlighting FASD using local media and health promotion talks at health facilities. Independently, two dysmorphologists and a neuropsychometrist examined children at 9 and 18 months.

RESULTS

Pre-intervention maternal knowledge of alcohol harms was low and FASD prevalence 8.9% (72/809). Interventions reached high coverage and knowledge levels increased substantially. FASD prevalence was 5.7% post-intervention (43/751; P = 0.02); 0.73 lower odds, controlling for maternal age and ethnicity (95% confidence interval = 0.58-0.90). No change was detected in more severe FASD forms, but in the whole population, median dysmorphology scores reduced from 4 [inter-quartile range (IQR) = 2-7] to 3 (IQR = 1-6; P = 0.002).

CONCLUSION

This, the first prevention study using FASD outcomes, suggests that universal prevention might reduce FASD by ∼30% and have population-level effects. This supports intensifying universal interventions where knowledge of harms of maternal drinking is low. These efforts need to be accompanied by alcohol-dependence treatment to lower more severe FASD forms.

A limited access mouse model of prenatal alcohol exposure that produces long-lasting deficits in hippocampal-dependent learning and memory

BACKGROUND

It has been estimated that approximately 12% of women consume alcohol at some time during their pregnancy, and as many as 5% of children born in the United States are impacted by prenatal alcohol exposure (PAE). The range of physical, behavioral, emotional, and social dysfunctions that are associated with PAE are collectively termed fetal alcohol spectrum disorder (FASD).

METHODS

Using a saccharin-sweetened ethanol solution, we developed a limited access model of PAE. C57BL/6J mice were provided access to a solution of either 10% (w/v) ethanol and 0.066% (w/v) saccharin or 0.066% (w/v) saccharin (control) for 4 h/d. After establishing consistent drinking, mice were mated and continued drinking during gestation. Following parturition, solutions were decreased to 0% in a stepwise fashion over a period of 6 days. Characterization of the model included measurements of maternal consumption patterns, blood ethanol levels, litter size, pup weight, maternal care, and the effects of PAE on fear-conditioned and spatial learning, and locomotor activity.

RESULTS

Mothers had mean daily ethanol intake of 7.17 ± 0.17 g ethanol/kg body weight per day, with average blood ethanol concentrations of 68.5 ± 9.2 mg/dl after 2 hours of drinking and 88.3 ± 11.5 mg/dl after 4 hours of drinking. Food and water consumption, maternal weight gain, litter size, pup weight, pup retrieval times, and time on nest did not differ between the alcohol-exposed and control animals. Compared with control offspring, mice that were exposed to ethanol prenatally displayed no difference in spontaneous locomotor activity but demonstrated learning deficits in 3 hippocampal-dependent tasks: delay fear conditioning, trace fear conditioning, and the delay nonmatch to place radial-arm maze task.

CONCLUSIONS

These results indicate that this model appropriately mimics the human condition of PAE and will be a useful tool in studying the learning deficits seen in FASD.

Ethanol-induced attenuation of oxidative stress is unable to alter mRNA expression pattern of catalase, glutathione reductase, glutathione-S-transferase (GST1A), and superoxide dismutase (SOD3) enzymes in Japanese rice fish (Oryzias latipes) embryogenesis

Although the mechanism of ethanol toxicity during embryogenesis is unknown, our earlier studies on Japanese rice fish (Oryzias latipes) embryos indicated that the effects might be mediated through oxidative stress. In this study we have determined the oxidative stress and the mRNA content of four antioxidant enzymes (catalase, glutathione reductase, glutathione-S-transferase, and superoxide dismutase) during Japanese rice fish embryogenesis (from 0 day post-fertilization to hatching) and after exposing the embryos to ethanol (100 and 300 mM) for 48 h at three stages (0-2, 1-3 and 4-6 days post-fertilization, dpf) of organogenesis. We observed that oxidative stress was minimal in blastula, gastrula or neurula stages, increased gradually with the advancement of morphogenesis and reached its maximum level in hatchlings. The antioxidant enzyme mRNAs were constitutively expressed throughout development; however, the expression pattern was not identical among the enzymes. Catalase and superoxide dismutase (SOD) mRNAs were minimal in the fertilized eggs, but increased significantly in 1 dpf and then either sharply dropped (SOD) or maintained a steady-state (catalase). Glutathione-S-transferase (GST) was very high in fertilized eggs and sharply dropped 1 dpf and then gradually increased thereafter. Glutathione reductase (GR) maintained a steady-state throughout the development. Ethanol was able to attenuate oxidative stress in embryos exposed only to 300 mM 1-3 dpf; no significant difference with controls was observed in other ethanol-treated groups. The antioxidant enzyme mRNAs also remained unaltered after ethanol treatment. From these data we conclude that the attenuation of oxidative stress by ethanol is probably due to the inhibition of normal growth of the embryos rather than by inhibiting catalase, GST, GR or SOD-dependent activities.